title: Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.
abstract: BACKGROUND
  In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.
  
  
  RESULTS
  We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed "not necessary" by a household decision maker. Among the poorest women, "not necessary" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended.
  
  
  CONCLUSIONS
  In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.
authors.affiliation: Global Health Group, University of California San Francisco, San Francisco, California, United States of America. montagud@globalhealth.ucsf.edu
authors.forename: Dominic
authors.initials: D
authors.lastname: Montagu
authors.forename: Gavin
authors.initials: G
authors.lastname: Yamey
authors.forename: Adam
authors.initials: A
authors.lastname: Visconti
authors.forename: April
authors.initials: A
authors.lastname: Harding
authors.forename: Joanne
authors.initials: J
authors.lastname: Yoong
mesh_terms: D016550:Birthing Centers / Q000191:economics / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000191:economics* / Q000379:methods* / Q000401:mortality; D003710:Demography; D003906:Developing Countries / Q000706:statistics & numerical data; D005260:Female; D006306:Health Surveys; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000191:economics; D008428:Maternal Mortality; D015337:Multicenter Studies as Topic; D036801:Parturition / Q000502:physiology; D011203:Poverty; D011247:Pregnancy